What are the indications for surgery in infective endocarditis (IE)?

Indications for Surgery in Infective Endocarditis

Surgery is required in approximately half of IE cases and is mandated for three primary indications: heart failure from severe valvular dysfunction, uncontrolled infection, and prevention of embolism. 1

1. Heart Failure (Most Common Indication)

Heart failure represents the most frequent complication and the leading indication for surgery in IE, occurring in 42-60% of cases. 1

Emergency Surgery (within 24 hours):

• Severe acute regurgitation, obstruction, or fistula causing refractory pulmonary edema or cardiogenic shock (Class I, Level B) 1, 2
• This applies to both native valve endocarditis (NVE) and prosthetic valve endocarditis (PVE) affecting aortic or mitral valves 1

Urgent Surgery (within a few days):

• Severe regurgitation or obstruction causing symptomatic heart failure or echocardiographic signs of poor hemodynamic tolerance (Class I, Level B) 1, 2
• Even a single transient episode of pulmonary edema warrants urgent surgery, particularly with aortic regurgitation 1, 3

Critical Point: The presence of heart failure mandates early surgery even in patients with cardiogenic shock, unless severe comorbidities make recovery remote. 1

2. Uncontrolled Infection

Urgent Surgery Required For:

• Locally uncontrolled infection including abscess, false aneurysm, fistula, or enlarging vegetation (Class I, Level B) 1, 2
• Infection caused by fungi or multiresistant organisms (Class I, Level C) 1, 2
• Persistent positive blood cultures despite appropriate antibiotics and adequate control of septic metastatic foci (Class IIa, Level B) 1
• Prosthetic valve endocarditis caused by staphylococci or non-HACEK gram-negative bacteria (Class IIa, Level C) 1, 4

Important Caveat: Persistent sepsis beyond the first week of appropriate antibiotic therapy should trigger surgical consultation. 5, 3

3. Prevention of Embolism

Urgent Surgery Indicated For:

• Persistent vegetations >10 mm after one or more embolic episodes despite appropriate antibiotic therapy (Class I, Level B) 1, 2
• Vegetations >10 mm associated with severe valve stenosis or regurgitation in low operative risk patients (Class IIa, Level B) 1
• Isolated very large vegetations >30 mm (Class IIa, Level B) 1
• Isolated large vegetations >15 mm with no other surgical indication (Class IIb, Level C) 1

Special Considerations

Neurological Complications:

• After silent embolism or transient ischemic attack, proceed with surgery without delay (Class I, Level B) 1, 2
• Following intracranial hemorrhage, postpone surgery for ≥1 month (Class IIa, Level B) 1
• Neurosurgery or endovascular therapy is indicated for very large, enlarging, or ruptured intracranial infectious aneurysms (Class I, Level C) 1, 2

Cardiac Device-Related IE:

• Complete hardware removal (device and all leads) plus prolonged antibiotic therapy is mandatory (Class I, Level C) 1, 2
• Percutaneous extraction is preferred even with vegetations >10 mm (Class I, Level B) 1, 2

Timing Algorithm

Emergency (within 24 hours): Refractory pulmonary edema or cardiogenic shock 1, 2

Urgent (within a few days):

• Symptomatic heart failure with poor hemodynamic tolerance 1, 2
• Locally uncontrolled infection 1, 2
• Fungal or multiresistant organisms 1, 2
• Persistent vegetations >10 mm after embolic event(s) 1, 2

Elective (after 1-2 weeks of antibiotics): Selected cases of fungal IE or multiresistant organisms with controlled infection 1

Critical Management Principles

• Early cardiac surgery consultation is essential for all IE cases to determine optimal therapeutic approach 1
• Surgery is justified when high-risk features make antibiotic cure unlikely, even during active infection 1
• Age alone is not a contraindication to surgery 1
• Decisions frequently require combining multiple high-risk features rather than a single indication 1
• All complicated IE cases should be managed at reference centers with immediate surgical capabilities and a multidisciplinary Endocarditis Team 1, 2

Common Pitfall: Delaying surgery in patients with heart failure while attempting prolonged antibiotic therapy leads to irreversible structural damage and increased mortality. 1